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APPLICATION FOR PERMIT y. SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZE.T ON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES TYEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District- Job Address �7 �� N City Lot Size PM Owner's Name .�/4Address _+ ` ,e� xi 4' —- 7ti Phone kvi�}r�� Contractor Address 2AIA4 PSZ2 License No."&i�Phane l TYPE OF WELL/PUMP: NEW WELL.N WELL REPLACEMENT © DESTRUCTION ❑ PUMP INSTALLATION SYSTEM REPAIR ❑ QTHER L2 % DISTANCE TO NEAREST: SEPTIC TANK1DEJ'J— SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION 149 AGRICULTURE WELL ___t— OTHER WELL 1 PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONSNO �r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation I Dia. of Well Casing i ADomestic/PrivateGravel Packs 17 Tracy Type of Casing__ �� Specifications iCL ��s Q r7 Public 1-1 Other fa Delta Depth of Grout Seal — Type of Grout V i 1-1 Irrigation ;WApprox. Depth I I Eastern Surf a Seal Installed by Repair Work Done ❑ Type of Pump I H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 50') f Depth Filler Material IBelow 501 i TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION i I DESTRUCTION I ! INo septic system permitted if public sewer is n available within 200 feet.) Installation will serve: Residence_ Commercial Other Number of living units: Number of bedrooms Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �^ PKG. TREATMENT PLT. ❑ Method of Disposal \ Distance to nearest: Well Foundation Property Line LEACHING LINE CI No. & Leng+h of lines Total length/size FILTER BED ❑ Distance to nearest: Well Foundation Property Line 1 SEEPAGE PITS C I Depth Size Number SUMPS CI Distance toInearest: Well Foundation Property Line DISPOSAL PONOS ❑ I hereby certify that I have prepared this application and that the;work will be done in accordance with San Joaquin county ordinances, state laws, arid rules and regulations of the San Joaquin Local Health District. J Home owner or licensed agent's signature certifies the following::"1 certify that in the performance of the work for which this permit is issued, I shall not employ : _ - t p y an y person in such manner as to become subject to workman's compensation laws of California." Contractor's'hiring or sub-contr.acting signature= certifies the following: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- x,.l tion laws of California." !�I The applicant f r all requir tions. Complete drawing on re Arse side. Signed X Title: Data: FOR DEPARTMENT USE ONLY ,s Application Accepted by Date 1� U—&—Arra Pit or Grout Inspection by Date .13 8l( Final Inspection by '41192i Dater, Additional Comments: ❑ Stk 466-6781 D Lodi 369-3621 ❑ Manteca •823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE 1 CK1 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. X R / 1 a.EH 1324 IREV.I/R 51 !!! EH 14-26